Impact of a multidisciplinary collaborative nutritional treatment model in patients who are critically ill with neurological disorders: A randomized controlled trial

BACKGROUND

Malnutrition is a widespread problem in critically ill patients with neurological disorders.

OBJECTIVE

The purpose of this study is to investigate the effect of a multidisciplinary collaborative nutritional treatment mode based on a standardized unit for nutritional support on the outcome metrics in patients with neurological disorders who are critically ill.

METHODS

We enrolled 84 participants who were hospitalized in the intensive care unit (ICU) of Yancheng No. 1 People's Hospital for neurological disorders between June 2018 and December 2021. The participants were randomly assigned to the control group and the test group. The control group received traditional nutritional support, while the test group was treated with a multidisciplinary collaborative nutritional treatment mode based on a standardized unit for nutritional support. We collected the general information, feeding tolerance (FT), nutritional risk score, and laboratory indicators before intervention, after intervention for one week, and after intervention for 2 weeks, and other data of the participants.

RESULTS

After the intervention, the test group scored significantly lower than the control group in the incidence of gastroparesis and diarrhea, as well as the NUTRIC score, with statistically significant differences (P< 0.001). The prealbumin levels in the test group increased progressively prior to intervention, after intervention for one week, and after intervention for two weeks. Compared to the control group, the test group had higher prealbumin levels prior to intervention, after intervention for one week, and after intervention for two weeks, with statistically significant differences (P< 0.001).

CONCLUSION

We developed a multidisciplinary collaborative nutritional treatment model based on a standard unit for nutritional support. This model can improve neural function, FT, and pertinent outcome indicators and is generally applicable.

Exploring the practice of nutritional support during hospitalization across physicians, dietitians, and pharmacists based in Saudi Arabia

Background

Nutritional support has a pivotal role in preventing and treating malnutrition. Recognizing the gaps in nutritional support practice can aid the development of tailored nutritional protocols. Therefore, this study aimed to assess the current practices, attitudes, and perceptions related to nutritional support for hospitalized patients in one of the largest Middle Eastern countries.

Methods

A cross-sectional study was conducted among different healthcare professionals currently working in hospitals in Saudi Arabia and involved in nutritional support practice. Data were collected using convenient sample via a self-administered web-based questionnaire.

Results

A total of 114 participants were included in this study. The majority were dietitians (54%), followed by physicians (33%) and pharmacists (12%), and were from the western region (71.9%). Various attitudes in many practices were observed among the participants. Only 44.7% of the participants had a formal nutritional support team. The mean confidence level of all respondents was significantly higher for enteral nutrition practice (7.7 ± 2.3) than for parenteral nutrition practice (6.1 ± 2.5) (p < 0.01). The confidence level for enteral nutrition practice was significantly influenced by nutritional qualification (β = 0.202, p < 0.05), type of healthcare facility (β = 0.210, p < 0.05), profession (β = -0.308, p < 0.01), and years of experience (β = 0.220, p < 0.05).

Conclusion

This study comprehensively assessed various aspects of nutritional support practice in Saudi Arabia. Healthcare practice of nutritional support should be guided by evidence-based guidelines. Professional qualification and training in nutritional support are essential for promoting practice in hospitals.

Nutrition support teams: Institution, evolution, and innovation

The historical institution, evolution, and innovations of nutrition support teams (NSTs) over the past six decades are presented. Focused aspects of the transition to transdisciplinary and patient-centered care, NST membership, leadership, and the future of NSTs are further discussed. NSTs were instituted to address the need for the safe implementation and management of parenteral nutrition, developed in the late 1960s, which requires the expertise of individuals working collaboratively in a multidisciplinary fashion. In 1976, the American Society for Parenteral and Enteral Nutrition (ASPEN) was established using the multidisciplinary model. In 1983, the United States established the inpatient prospective payment system with associated diagnosis-related groupings, which altered the provision of nutrition support in hospitals with funded NSTs. The number of funded NSTs has waxed and waned since; yet hospitals and healthcare have adapted, as additional education and experience grew, primarily through ASPEN's efforts. Nutrition support was not administered in some instances by the "core of four" (physician, nurse, dietitian, pharmacist). The functions may be carried out by a member of the core of four not associated with the parent discipline, in accordance with licensure/privileging. This cross-functioning has evolved into the adaptation of the concept of transdisciplinarity, emphasizing function over form, supported and enhanced by "top-of-license" practice. In some institutions, nutrition support has been incorporated into other healthcare teams. Future innovations will assist NSTs in providing the right nutrition support for the right patient in the right way at the right time, recognizing that nutrition care is a human right.

Identifying the nutrition support nurses' tasks using importance-performance analysis in Korea: a descriptive study

PURPOSE

Nutrition support nurse is a member of a nutrition support team and is a health care professional who takes a significant part in all aspects of nutritional care. This study aims to investigate ways to improve the quality of tasks performed by nutrition support nurses through survey questionnaires in Korea.

METHODS

An online survey was conducted between October 12 and November 31, 2018. The questionnaire consists of 36 items categorized into 5 subscales: nutrition-focused support care, education and counseling, consultation and coordination, research and quality improvement, and leadership. The importance-performance analysis method was used to confirm the relationship between the importance and performance of nutrition support nurses' tasks.

RESULTS

A total of 101 nutrition support nurses participated in this survey. The importance (5.56±0.78) and performance (4.50±1.06) of nutrition support nurses' tasks showed a significant difference (t=11.27, P<0.001). Education, counseling/consultation, and participation in developing their processes and guidelines were identified as low-performance activities compared with their importance.

CONCLUSION

To intervene nutrition support effectively, nutrition support nurses should have the qualification or competency through the education program based on their practice. Improved awareness of nutrition support nurses participating in research and quality improvement activity for role development is required.

Systematic review with meta-analysis: effects of implementing a nutrition support team for in-hospital parenteral nutrition

BACKGROUND

Nutrition support teams (NST) may improve parenteral nutrition (PN) outcomes. No previous systematic review has provided conclusive data on catheter-related infection (CRI) occurrence after NST introduction, nor have previous studies performed meta-analysis or graded the evidence.

AIMS

To systematically evaluate the effects of implementing an NST for hospitalised adults on PN and compare these with standard care.

METHODS

This was a systematic review and meta-analysis, pre-registered in PROSPERO (CRD42020218094). On November 24, 2020, PubMed, Web of science, Scopus, Embase, Cochrane Library, and Clinical Key were searched. Clinical trials and observational studies with a standard care comparator were included. Primary outcome was relative reduction in CRI rate. A random-effects meta-analysis was used to estimate effects, and evidence was rated using Cochrane and GRADE methodologies.

RESULTS

Twenty-seven studies with 8166 patients were included. Across 10 studies, NST introduction reduced the CRI rate (IRR = 0.32, 95% CI: 0.19-0.53) with -8 (95% CI: -12 to -5) episodes per 1000 catheter days compared with standard care. Hypophosphataemia occurred less frequently (IRD = -12%, 95% CI: -24% to -1%) and 30-day mortality decreased (IRD = -6%, 95% CI: -11% to -1%). Inappropriate PN use decreased, both judged by indication (IRD = -18%, 95% CI: -28% to -9%) and duration (IRD = -21%, 95% CI: -33% to -9%). Evidence was rated very low to moderate.

CONCLUSIONS

This study documents the clinical impact of introducing an NST, with moderate-grade evidence for the reduction of CRI occurrence compared with standard care. Further, NST introduction significantly reduced metabolic complications, mortality, and inappropriate PN use.

Critical analysis of factors affecting the efficiency of nutrition therapy teams

BACKGROUND

Nutrition therapy (NT), defined as the provision of oral, enteral, or parenteral nutrition, should be considered a part of the holistic approach to patient care, while quality assessment of its practices is crucial. The present study aimed to identify variables capable of explaining the reason behind compliance of NTTs with the regulatory requirements.

METHODS

A cross-sectional study focused on assessing the quality of nutritional therapy practices among NTTs who previously stated to be able to comply with requirements of the Brazilian law versus those who were not able to meet these demands. Hospitals were classified as A (teams that had previously reported to be able to meet the requirements) and B (those unable to comply with them). The study was approved by the ethics committees of all participant institutions.

RESULTS

Twenty six hospitals met the inclusion criteria. The main hospital features, such as size, classification, service type, and percentage of hospitals providing NT were similar. Hospitals differed on the median number of patients undergoing NT per week: in group B (41.0; IR = 28.0-58.0) and group A (11.0; IR = 5.0-48.0) (p < 0.05), but there were no differences regarding personnel expertise. Both hospital groups had low quality control of the NT processes.

CONCLUSION

Lack of quality assurance is responsible for the inadequate services in both type of institutions.

Parenteral nutrition in emergency surgery: A multicentre cross-sectional study

BACKGROUND

Emergency general surgical patients are inherently at high risk of malnutrition. Early decision-making with implementation is fundamental to patient recovery. For many patients, parenteral nutrition (PN) is the only feeding option available. The present study assessed the timing and outcomes of this decision-making process.

METHODS

A sample of at least 10 consecutive adult patients admitted as a general surgical emergency to eight UK hospitals over 1 year who had received PN was identified. Patient demographics, basic descriptors and nutritional data were captured. Process measures regarding dates decisions were made or activities completed were extracted from records, as were outcome measures including PN complications. Six time frames examining the process of PN delivery were analysed. Associations between categorical and binary variables were investigated with a chi-squared test with significance determined as p < 0.05.

RESULTS

In total, 125 patients were included. Intestinal obstruction was the most common diagnosis with 59% of all patients deemed high risk on nutritional assessment at admission. Median time to decision for PN was 5 days following admission (n = 122, interquartile range = 7). Patients received PN for a mean of 11 days. Eighty-five percent of patients developed a complication, with a phosphate abnormality being the most commonly reported (54%). Only altered blood glucose levels appeared to correlate with a delay in starting PN (p < 0.01).

CONCLUSIONS

The present study shows there are delays in the decision to use PN in the acutely ill surgical patient. Once initiated, the pathway is relatively short. There are high rates of electrolyte abnormalities in this population.

Effect of the Timing of Nutritional Support Team Intervention on Nutritional Status on Patients Receiving Enteral Nutrition

Many hospitalized patients usually have a high risk of malnutrition, which delays the therapy process and can lead to severe complications. Despite of the potential benefits, the effects of timely intervention by nutrition support team (NST) on the nutritional status of admitted patients are not well established. This study aimed to compare the nutritional status between patients with early and delayed NST supports and to assess the effect of the timing of NST support initiation on the nutritional status of enteral nutrition patients. In a simple comparison between the two groups, the early NST intervention group had shorter hospital stays and fewer tube feeding periods than the delayed NST intervention group. The increase in the amount of energy intake from first to last NST intervention was 182.3 kcal in patients in the early NST intervention group, higher than that in patients in the delayed intervention group (p = 0.042). The extent of reduction in serum albumin and hemoglobin levels between the initial and last NST intervention tended to be lower in the early NST intervention group than in the delayed NST intervention group. The mean odds ratio for the patients who were severely malnourished in the early NST intervention group was 0.142 (95% confidence interval, 0.045–0.450) after adjusting for hospital stay and age. The results of this study indicate that early NST intervention can improve patients' overall nutritional status.

[Pillars for excellence in nutrition support units. Regulation]

Introduction

Nutritional assessment and treatment, necessary for the prevention and treatment of disease-related malnutrition, should be carried out by a multidisciplinary team where each member has well-defined skills and functions, and mechanisms are established to allow adequate coordination, both in the inpatient and outpatient settings. In Spain, the development and implementation of these teams or units dedicated to clinical nutrition has been very important: today they are present in most hospitals. This paper reviews the characteristics of clinical nutrition units, the functions of their team members, and the regulatory framework in our country.

Trends and Novel Research in Hospital Nutrition Care: A Narrative Review of Leading Clinical Nutrition Journals

Hospital malnutrition is a longstanding problem that continues to be underrecognized and undertreated. The aim of this narrative review is to summarize novel, solution-focused, recent research or commentary to update providers on the prevention of iatrogenic malnutrition as well as the detection and treatment of hospital malnutrition. A narrative review was completed using the top 11 clinically relevant nutrition journals. Of the 13,850 articles and editorials published in these journals between 2013 and 2019, 511 were related to hospital malnutrition. A duplicate review was used to select (n = 108) and extract key findings from articles and editorials. Key criteria for selection were population of interest (adult hospital patients, no specific diagnostic group), solution-focused, and novel perspectives. Articles were categorized (6 classified in >1 category) as Screening and Assessment (n = 17), Standard (n = 25), Advanced (n = 12) and Specialized Nutrition Care (n = 8), Transitions (n = 15), Multicomponent (n = 21), Education and Empowerment (n = 9), Economic Impact (n = 3), and Guidelines (n = 4) for summarizing. Research advances in screening implementation, standard nutrition care, transitions, and multicomponent interventions provide new strategies to consider for malnutrition prevention (iatrogenic), detection, and care. However, several areas requiring further research were identified. Specifically, larger and more rigorous studies that examine health outcomes and economic analyses are urgently needed.

Parenteral Provision of Micronutrients to Adult Patients: An Expert Consensus Paper

BACKGROUND

Micronutrients, an umbrella term used to collectively describe vitamins and trace elements, are essential components of nutrition. Those requiring alternative forms of nutrition support are dependent on the prescribed nutrition regimen for their micronutrient provision. The purpose of this paper is to assist clinicians to bridge the gap between the available guidelines' recommendations and their practical application in the provision of micronutrients via the parenteral route to adult patients.

METHODS

Based on the available evidenced-based literature and existing guidelines, a panel of multidisciplinary healthcare professionals with significant experience in the provision of parenteral nutrition (PN) and intravenous micronutrients developed this international consensus paper.

RESULTS

The paper addresses 14 clinically relevant questions regarding the importance and use of micronutrients in various clinical conditions. Practical orientation on how micronutrients should be prescribed, administered, and monitored is provided.

CONCLUSION

Micronutrients are a critical component to nutrition provision and PN provided without them pose a considerable risk to nutrition status. Obstacles to their daily provision-including voluntary omission, partial provision, and supply issues-must be overcome to allow safe and responsible nutrition practice.

Modern Challenges to Gastrointestinal Nutrition Physicians and the Nutrition Support Team: Cautionary Tales and Call to Action

The current climate of healthcare economics in the United States has imposed unprecedented market stressors on health institutions traditionally providing tertiary care to those with the most challenging healthcare needs. In such a stressed financial atmosphere, administrators look to streamline costs and cut margins as tightly as possible. This often results in restructuring, consolidating, or closing service lines that are perceived as unprofitable or unsupportable. Nutrition support often falls into this category because of few sources of direct revenue-generating activities and poor reimbursement from third-party payers. This article discusses the challenges to modern nutrition support teams, particularly those with gastroenterologists as physician leaders, and delineates market forces that need shifting to continue to make this a viable part of the healthcare system.

To PEG or not to PEG that is the question

Nutrition support involves the use of oral supplements, enteral tube feeding or parenteral nutrition. These interventions are considered when oral intake alone fails to meet nutritional requirements. Special diets and oral supplements are usually the first approach to managing malnutrition; however, their role becomes limited when oral intake is restricted or if swallowing is unsafe. Enteral tube feeding or parenteral nutrition are alternative means of providing nutrition support for this select group of patients. Percutaneous endoscopic gastrostomy (PEG) feeding was introduced into clinical practice in 1980. It describes a feeding tube placed directly into the stomach under endoscopic guidance. It is an established means of providing enteral nutrition to those who have functionally normal gastrointestinal tracts, but who cannot meet their nutritional requirements due to inadequate oral intake. The intervention is usually reserved when nutritional intake is likely to be inadequate for more than 4-6 weeks. Although the benefits of PEG have been shown for a select group of patients, there currently exists concerns about the increasing frequency of this intervention, and also uncertainty about the long-term benefits for certain patients. The 2004 UK National Confidential Enquiry into Patient Outcome and Death report emphasised this concern, with almost a fifth of PEG being undertaken for futile indications that negatively influenced morbidity and mortality. The present review paper discusses the indications for, controversies surrounding and complications of gastrostomy feeding and provides practical advice on optimising patient selection for this intervention.

Demonstrating the Value of the Nutrition Support Team to the C-Suite in a Value-Based Environment: Rise or Demise of Nutrition Support Teams?

Nutrition support teams (NSTs) in the United States have had to justify their existence since their inception in the 1970s. Concomitant with those efforts, changes in healthcare financing have challenged hospital administrators to adapt their reimbursement strategies and methods. NSTs, if they are to survive and/or thrive, must be aware of the convulsive currents of change faced by those who determine which programs move downstream and which find their demise on the banks of the stream. This review provides a historical perspective of both the US healthcare financing system and the NST experiences of nutrition clinicians over the past 4 decades. Focused discussions of 5 teams are provided from individual members of those varied NSTs. Additional recommendations from the administrative side of the equation are presented by 3 administrators. Whether NSTs will "rise or demise" depends on many factors. Understanding what those who control the purse strings are seeking in terms of salutary cost and quality outcomes in the current value-based system will facilitate the NST's communication with them. The demonstration of the NST's value is more likely to succeed when bolstered by current evidence-based data as applied to the specific institution. These efforts can be carried out by a formal NST in larger or academic institutions or a "virtual" team with a single individual coordinating the services in a transdisciplinary fashion, employing the acronym ACT (accountability, communication, [transdisciplinary] teamwork).

Nutrition Support Teams: A Systematic Review

BACKGROUND

The concept of a nutrition support team (NST) was first introduced at the end of the 20th century in the US and Europe. Expected benefits include reduced (inappropriate) prescription of (par)enteral nutrition; however, to the authors' knowledge, no recent review has assessed the effectiveness of NSTs. Therefore, this systematic review evaluated the effectiveness of NSTs with respect to the prevalence of adult patients receiving (par)enteral nutrition.

METHODS

Five literature databases were searched and completed by citing searches. Studies on NSTs that were published between 2000 and 2018 in Western countries, applied a comparative design, and contained at least outcome data on the prevalence of (par)enteral nutrition were included. Analyses were mainly descriptive because of high heterogeneity that prevented meta-analyses.

RESULTS

The 27 included studies mainly originated from the UK and US. Only 1 of the included studies was a randomized trial; the other studies had a pre-post design (n = 17) or compared groups in a nonrandomized way. All but 2 studies were performed in acute care hospitals, and 5 studies focused only on intensive care patients. There was conflicting evidence of whether NSTs lead to reduction or increase in patients starting parenteral nutrition (PN); however, weak evidence suggested that NSTs might lead to an increase in the ratio of enteral nutrition to PN use and might decrease inappropriate PN use.

CONCLUSION

Although almost all studies concluded in favor of NSTs, the evidence base is weak and insufficient because of a lack of well-designed studies and successful outcomes.

The Role of a Nutrition Support Team in the Management of Intestinal Failure Patients

Parenteral nutrition (PN) is a complex and specialized form of nutrition support that has revolutionized the care for both pediatric and adult patients with acute and chronic intestinal failure (IF). This has led to the development of multidisciplinary teams focused on the management of patients receiving PN: nutrition support teams (NSTs). In this review we aim to discuss the historical aspects of IF management and NST development, and the practice, composition, and effectiveness of multidisciplinary care by NSTs in patients with IF. We also discuss the experience of two IF centers as an example of contemporary NSTs at work. An NST usually consists of at least a physician, nurse, dietitian, and pharmacist. Multidisciplinary care by an NST leads to fewer complications including infection and electrolyte disturbances, and better survival for patients receiving short- and long-term PN. Furthermore, it leads to a decrease in inappropriate prescriptions of short-term PN leading to significant cost reduction. Complex care for patients receiving PN necessitates close collaboration between team members and NSTs from other centers to optimize safety and effectiveness of PN use.

Tutorial on Diarrhea and Enteral Nutrition: A Comprehensive Step-By-Step Approach

This tutorial suggests a current strategy toward a multiprofessional therapy based upon a comprehensive step-by-step approach to the course of intensive care unit diarrhea episodes. Evidence published in the last 10 years, obtained through a database search (PubMed), shows that its prevalence is quite variable. Although multicausal, it is often erroneously associated with the supply of enteral nutrition. Several complications affect not only nutrition status but also the development of skin lesions, which can become the focus of infections, and the length of hospital stay. Here, we propose an early, objective, directed, and multimodal approach, aiming at optimizing care for these patients. In a dynamic walkthrough, the reader will find a guide for the general diagnosis and for colitis resulting from Clostridium difficile infections, as well as current instructions and recommendations for drug treatment and supportive therapy for these 2 modalities. We also bring together ways to prevent and treat associated skin lesions in this setting. Because it is neglected in the critical environment, diarrhea is still a poorly addressed disease, and its complications bring about a significant worsening in quality of life and hospital stay.

The role of the dietitian in the management of malnutrition in the elderly: A systematic review of current practices

AIM

The prevalence of age-related malnutrition is increasing in almost all Western countries. Because of their expertise, dietitians should have a central role in the management of malnutrition. This review aimed to synthesise the literature on the role of the dietitian in the management of malnutrition in the elderly in comparison with other health professionals.

METHODS

In November 2018, a search of Embase, Medline Ovid, Cinahl Ebscohost, Cochrane Central, Web of Science and Google Scholar was undertaken using 'dietitian', 'elderly' and 'malnutrition' as the main search terms. Qualitative and quantitative empirical research studies that focussed on the role of dietitians as the (main) subject of the study were included. Data extraction and data synthesis were performed by the three authors using a thematic synthesis approach.

RESULTS

Three themes emerged from the coding and synthesis of the 21 included studies. The first theme demonstrates that other health professionals' time for, and knowledge of, screening policies negatively affects the role of the dietitian. The second theme demonstrates that the importance of nutritional care is acknowledged. However, this does not always imply familiarity with dietetics nor does it always mean that other health professionals think involving dietitians is worth the effort. The third theme demonstrates that issues of workload appeared to be especially important in crossing or guarding role boundaries.

CONCLUSIONS

The role of dietitians in managing age-related malnutrition is not always clear and coherent. Therefore, how dietitians shape their role to provide optimal management of malnutrition in the elderly is open to debate.

Navigating the Challenges of Home Parenteral Nutrition

Providing parenteral nutrition at home has significant challenges for both patients and providers alike. Some of these challenges are systemic and are secondary to the way the healthcare system is designed to deliver care. Others are more practical and require educating patients and their families to ensure success at home. Overall, the nutrition support team was designed to help deal with these challenges in an effective way. The changing realities of the modern health system are challenging the nutrition support team to adapt to new obstacles. Providing patients with the tools to succeed at home requires a significant amount of time and investment but will pay dividends in the future as patients thrive for years to come.

Impact of interprofessional education for medical and nursing students on the nutritional management of in-patients

Introduction: Despite its frequency, malnutrition is underestimated in its importance for morbidity and mortality. Interprofessional nutrition management can improve patient safety and clinical outcomes. An interprofessional education is considered as the basis for good team cooperation. So far, little data is available on the effects of interprofessional education on measurable outcomes for patients. The objective is to determine to what extent student feedback leads to a change of in-patient nutritional management for a selected internal medical ward. Methodology: In a teaching project based on the method of research oriented learning, medical and nursing students conducted an analysis of the nutritional situation of patients and developed individual treatment plans. The students orally reported their findings to the care teams as well as via a poster presentation to decision-makers of the clinic. A prospective cohort intervention study was conducted to assess the nutritional status of patients before and after student interventions using established screening tools. Differences were tested using t-test and Fisher's exact test. Institutional consequences for nutrition management were recorded descriptively. The teaching unit was evaluated by the students before and after. Results: Malnutrition was found in 59% of patients. Inspired by student feedback, institutional consequences followed: a) routine inpatient screening using Nutritional Risk Screening; and b) the use of pie charts to estimate food intake. Conclusion: The feedback from the results of student interprofessional cooperation led to a sensitization of decision-makers and enabled new measures to improve nutritional management. These can increase patient safety.

Association between indication for therapy by nutrition support team and nutritional status

The nutrition support team is a multidisciplinary team composed of medical doctors, registered nurses, pharmacists, and nutritionists, who evaluate the nutritional status of patients. The objective of this study was to determine the relationship between indications for nutrition support team therapy and the nutritional status of patients hospitalized in local major hospitals.Patients who were referred to a nutrition support team from January to December 2016 were enrolled. Patients were classified into 4 age groups, and the weight categories were determined using body mass index (BMI). Four of 6 indications were used for referral to a nutrition support team. The required calories were estimated, and the nutritional status was classified into malnutrition or eutrophia, based on the estimation.The proportion of elderly patients (37.0%) was higher than that of younger ones (28.3%). Patients with higher BMI had a relatively lower proportion of malnutrition. Patients receiving enteral nutrition had greater risk of malnutrition (adjusted odds ratio [aOR] = 3.77, 95% confidence interval [CI] = 2.71-5.24). Patients receiving parenteral nutrition (aOR = 0.38, 95% CI = 0.30-0.47) and treated in the intensive care unit (aOR = 0.70, 95% CI = 0.54-0.91) had lower risk of malnutrition. Patients with >3 indications for nutrition support team therapy had a lower risk of malnutrition than those with only 1 indication (aOR = 0.54, 95% CI = 0.37-0.77).Parenteral nutrition was the most common indication for referral to nutrition support team therapy; however, enteral nutrition had the poorest nutritional status. Patients receiving enteral nutrition who are referred to a nutrition support team need an intensive nutrition support strategy.

The impact of using a malnutrition screening tool in a hospital setting: a mixed methods study

BACKGROUND/OBJECTIVES

Malnutrition risk screening represents a crucial starting point for the successful management of malnourished patients. This study was conducted to (1) examine the effect of the use of a malnutrition screening tool on process indicators of nutritional care and (2) explore healthcare professionals' perceptions and opinions regarding this tool.

METHODS

A mixed methods design was used. A controlled pretest-posttest study was conducted to carry out quantitative analyses, and semi-structured, qualitative interviews were held. Quantitative data were analysed with descriptive statistics, Chi-squared tests, Student's t-tests and Kruskal-Wallis H tests, using SPSS 23. Qualitative data were analysed by performing a qualitative content analysis using MAXQDA 12. Two comparable hospitals participated in the study, representing one intervention group (IG) and one control group (CG). The Graz Malnutrition Screening Tool (GMS) was implemented and used in the IG for at least 1 month, while the CG received no intervention.

RESULTS

The use of the screening tool positively correlated with significant improvements in the process indicators of nutritional care after 1 month, in terms of the number of nutritional interventions and the frequency of documentation of the diagnosis and the patient's weight and height. The content of the interviews revealed that nearly all professionals involved perceived the overall screening process positively. Few barriers were identified.

CONCLUSIONS

The results of this study show that the use of a screening tool has a positive, short-term impact on the hospital's process quality of nutritional care. Ongoing efforts are required to sustainably maintain these positive changes. During this process, positive attitudes, nomination of motivated 'opinion-leaders' and concerted management support are helpful facilitators.

Role of pharmacists in providing parenteral nutrition support: current insights and future directions

BACKGROUND

Parenteral nutrition (PN) therapy is a complex and critical therapy that requires special clinical knowledge, skills, and practice experience to avoid errors in prescribing, compounding, and clinical management of patients. Pharmacists with adequate clinical training and expertise in PN therapy can have pivotal role in the care of patients receiving PN therapy.

OBJECTIVE

The aim of this systematic review was to describe and evaluate the different roles of pharmacists and their provided services related to PN therapy.

MATERIALS AND METHODS

A comprehensive systematic literature review on the topic was conducted via PubMed database using several keywords related to the topic (from 1975 to 2017). Additional resources included the standards of practice and clinical guidelines from recognized organizations such as the American Society for Parenteral and Enteral Nutrition (ASPEN) and the American Society of Health-System Pharmacists (ASHP).

RESULTS

Pharmacists have diverse roles in relation to PN therapy including the following: the assessment of patients' nutritional needs; the design, compounding, dispensing, and quality management of PN formulations; monitoring patients' response to PN therapy; supervision of home parenteral nutrition (HPN) programs; education of patients, caregivers, and other health care professionals on nutrition support and conducting PN-related research and quality improvement activities. These services seem to be variable across clinical settings and among different countries depending on the practice environment and pharmacists' clinical practice in these settings. However, each of these practice domains helps to support the delivery of safe and effective PN therapy to patients.

CONCLUSION

Pharmacists have been actively participating in providing PN-related services to patients. To fulfill the requirements of their essential role in this area of practice, pharmacists need adequate educational preparation and clinical training on nutrition support. Empowerment of pharmacists to assume a stronger leadership role in this dimension of pharmacy practice will enhance the quality of care provided to patients receiving PN therapy and improve PN services.

Nutrition support team activities can improve enteral nutrition administration in intensive care units

OBJECTIVES

The aim of this study was to evaluate the effect of the nutritional support team (NST) activities on the quality of enteral nutrition administration in intensive care units.

METHODS

An observational, analytical, and cross-sectional study was performed in nine hospitals in the Brazilian Federal District through the administration of two questionnaires. One questionnaire focused on the activities of the NST and the other on the quality of enteral nutrition administration in intensive care units.

RESULTS

There was a strong correlation between the scores of the two questionnaires, which was confirmed by a linear regression model (R² = 0.623; P = 0.007). The results suggest that high scores in the NST activities questionnaire predict a better performance in enteral nutrition administration. The sections of the NST activity questionnaire that most strongly affected enteral nutrition administration were the protocols (r = 0.895; P < 0.01), quality control (r = 0.779; P < 0.05), and continuing education (r = 0.753; P < 0.05).

CONCLUSIONS

The NST has the potential to positively influence enteral nutrition management in intensive care units and investments could be directed to the areas of continuing education, protocols, and quality control to maximize the effect of NST in intensive care units.

Development and validation of a questionnaire to evaluate the state of Iranian hospital nutrition support

Background

Recently, nutrition support was implemented as a part of clinical services in hospitals. The implementation of nutrition support needs to be assessed for its improvement.

Objective

This study aimed to develop and validate a questionnaire to assess the state of nutrition support in Iranian hospitals.

Methods

A mixed method approach was used in this study. This study was performed in training hospitals of Iran in 2016. In the development stage, pre-determined keywords were searched on international electronic databases. Additionally, semi-structural interviews were performed with 13 key informants based on purposive sampling. Themes were extracted from articles and interviews by thematic analysis. A primary questionnaire was generated based on extracted themes. In the validating stage, the content validity ratio (CVR) and content validity index (CVI) were used. The reliability of the questionnaire was also computed through a pilot study using Cronbach’s alpha test. SPSS version 16.0 was used for data analysis.

Results

Based on 16 items elicited from the content analysis, 110 questions were generated, out of which, 65 questions were selected. Then, 55 questions showing acceptable CVI and CVR were chosen for the pilot study. The Cronbach’s alpha coefficient of the questionnaire was found to be 0.80. This value remained stable for each item, even after an item was deleted.

Conclusion

For the first time, a validated questionnaire for the assessment of the state of nutrition support in hospitals was developed in a methodological approach process with high validity and reliability indexes which intended to be comprehensive based on the mixed method approach.

Impact and outcomes of nutritional support team intervention in patients with gastrointestinal disease in the intensive care unit

Nutritional support has become an important intervention for critically ill patients. Many studies have reported on the effects of nutritional support for the patients within the intensive care unit (ICU); however, no studies have specifically assessed patients with gastrointestinal diseases who may have difficulty absorbing enteral nutrition (EN) in the ICU.Sixty-two patients with gastrointestinal disease were admitted to the ICU between August 2014 and August 2016 at a single tertiary university hospital. We analyzed 2 different patient groups in a retrospective cohort study: those who received nutritional support team (NST) intervention and those who did not.Forty-four (71.0%) patients received nutritional support in ICU and 18 (29.0%) did not. Variables including male sex, high albumin or prealbumin level at the time of ICU admission, and short transition period into EN showed statistically significant association with lower mortality on the univariate analysis (all P < .05). Multivariate analysis revealed that longer length of hospital stay (P = .013; hazard ratio [HR], 0.972; 95% confidence interval [CI], 0.951-0.994), shorter transition into EN (P = .014; HR, 1.040; 95% CI, 1.008-1.072), higher prealbumin level (P = .049; HR, 0.988; 95% CI, 0.976-1.000), and NST intervention (P = .022; HR, 0.356; 95% CI, 0.147-0.862) were independent prognostic factors for lower mortality.In conclusion, NST intervention related to early initiated EN, and high prealbumin levels are beneficial to decrease mortality in the acutely ill patients with GI disease.

Stuck in tradition-A qualitative study on barriers for implementation of evidence-based nutritional care perceived by nursing staff

AIMS AND OBJECTIVES

To explore the barriers for nutritional care as perceived by nursing staff at an acute orthopaedic ward, aiming to implement evidence-based nutritional care.

BACKGROUND

Previous studies indicate that nurses recognise nutritional care as important, but interventions are often lacking. These studies show that a range of barriers influence the attempt to optimise nutritional care. Before the implementation of evidence-based nutritional care, we examined barriers for nutritional care among the nursing staff.

DESIGN

Qualitative study.

METHODS

Four focus groups with thirteen members of the nursing staff were interviewed between October 2013-June 2014. The interview guide was designed according to the Theoretical Domains Framework. The interviews were analysed using qualitative content analysis.

RESULTS

Three main categories emerged: lacking common practice, failing to initiate treatment and struggling with existing resources. The nursing staff was lacking both knowledge and common practice regarding nutritional care. They felt they protected patient autonomy by accepting patient's reluctance to eat or getting a feeding tube. The lack of nutritional focus from doctors decreased the nursing staffs focus leading to nonoptimal nutritional treatment. Competing priorities, physical setting and limited nutritional supplements were believed to hinder nutritional care.

CONCLUSION

The results suggest that nutritional care is in a transitional state from experience- to evidence-based practice. Barriers for nutritional care are grounded in lack of knowledge among nursing staff and insufficient collaboration between nursing staff and the doctors. There is a need for nutritional education for the nursing staff and better support from the organisation to help nursing staff provide evidence-based nutritional care.

RELEVANCE TO CLINICAL PRACTICE

This study contributes with valuable knowledge before the implementation of evidence-based nutritional care. The study provides an understanding of barriers for nutritional care and presents explanations to why nutritional care has failed to become an integrated part of the daily treatment and care.

Hospital Malnutrition Related to Fasting and Underfeeding: Is It an Ethical Issue?

Hospital malnutrition is a relevant clinical issue present in about 50% of patients that is associated with increased morbidity, mortality, and cost of care. Because of the relation of malnutrition with chronic and acute inflammatory processes secondary to disease, nutrition therapy is considered an important medical treatment. However, there is little discussion about the impact of another critical issue related to hospital malnutrition, that is, lack of appropriate food or nutrition therapy given to the patients. Unnecessary fasting practices and the use of inappropriate nutrition prescriptions result in underfeeding that can be a related or direct cause of hospital malnutrition, independent of disease or inflammatory state. Suboptimal prescription of oral, enteral, and parenteral nutrition should be analyzed and discussed from an ethical perspective since this practice has the potential to harm patients. In addition, absence or inadequate provision of nutrition may present barriers for improved patient outcomes and could be prevented by simply recognizing lack of knowledge, skills, or experience in nutrition and entrusting nutrition prescription to interdisciplinary teams with clinicians well prepared in nutrition sciences. This article reviews potential barriers to the prevention or treatment of hospital malnutrition and proposes specific actions that can help clinicians to overcome and implement optimal nutrition not just as medical therapy but also as a basic comfort care that may help patients nutritionally, clinically, physically, and emotionally.

When Is Parenteral Nutrition Appropriate?

Parenteral nutrition (PN) represents one of the most notable achievements of modern medicine, serving as a therapeutic modality for all age groups across the healthcare continuum. PN offers a life-sustaining option when intestinal failure prevents adequate oral or enteral nutrition. However, providing nutrients by vein is an expensive form of nutrition support, and serious adverse events can occur. In an effort to provide clinical guidance regarding PN therapy, the Board of Directors of the American Society for Parenteral and Enteral Nutrition (ASPEN) convened a task force to develop consensus recommendations regarding appropriate PN use. The recommendations contained in this document aim to delineate appropriate PN use and promote clinical benefits while minimizing the risks associated with the therapy. These consensus recommendations build on previous ASPEN clinical guidelines and consensus recommendations for PN safety. They are intended to guide evidence-based decisions regarding appropriate PN use for organizations and individual professionals, including physicians, nurses, dietitians, pharmacists, and other clinicians involved in providing PN. They not only support decisions related to initiating and managing PN but also serve as a guide for developing quality monitoring tools for PN and for identifying areas for further research. Finally, the recommendations contained within the document are also designed to inform decisions made by additional stakeholders, such as policy makers and third-party payers, by providing current perspectives regarding the use of PN in a variety of healthcare settings.

Intestinal Failure in Children

Children with intestinal failure have had improved survival, particularly those with extreme short bowel syndrome, over the last 10-15 y. This has been attributed to better understanding of the pathophysiology of intestinal failure, improvement in line care, recognition of the importance of a team approach as well as the progress of intestinal transplant as a viable option. Parenteral nutrition remains the cornerstone for the continual survival of these patients. This review will cover contemporary approaches to intestinal failure including post surgical approaches, non-transplant surgery, dietetic and medication approaches during the adaptation process, considerations for home parenteral nutrition and latest in intestinal transplantation.

Parenteral Nutrition Utilization After Implementation of Multidisciplinary Nutrition Support Team Oversight: A Prospective Cohort Study

BACKGROUND

Multidisciplinary nutrition teams can help guide the use of parenteral nutrition (PN), thereby reducing infectious risk, morbidity, and associated costs. Starting in 2007 at Harborview Medical Center, weekly multidisciplinary meetings were established to review all patients receiving PN. This study reports on observed changes in utilization from 2005-2010.

MATERIALS AND METHODS

All patients who received PN from 2005-2010 were followed prospectively. Clinical data and PN utilization data were recorded. Patients were grouped into cohorts based on exposure to weekly multidisciplinary nutrition team meetings (from 2005-2007 and from 2008-2010). Patients were also stratified by location, primary service, and ultimate disposition.

RESULTS

In total, 794 patients were included. After initiation of multidisciplinary nutrition meetings, the rate of patients who started PN decreased by 27% (relative risk [RR], 0.73; 95% confidence interval [CI], 0.63-0.84). A reduction in the number of patients receiving PN was observed in both the intensive care unit (ICU) and on the acute care floor (RR, 0.64; 95% CI, 0.53-0.77 and RR, 0.80; 95% CI, 0.64-0.99, respectively). The rate of patients with short-duration PN use (PN duration of <5 days) declined by 30% in the ICU (RR, 0.70; 95% CI, 0.51-0.97) and by 27% on acute care floors (RR, 0.73; 95% CI, 0.51-1.03).

CONCLUSIONS

Weekly multidisciplinary review of patients receiving PN was associated with reductions in the number of patients started on PN, total days that patients received PN, and number of patients who had short-duration (<5 days) PN use.

ESPEN guidelines on nutrition in cancer patients

Cancers are among the leading causes of morbidity and mortality worldwide, and the number of new cases is expected to rise significantly over the next decades. At the same time, all types of cancer treatment, such as surgery, radiation therapy, and pharmacological therapies are improving in sophistication, precision and in the power to target specific characteristics of individual cancers. Thus, while many cancers may still not be cured they may be converted to chronic diseases. All of these treatments, however, are impeded or precluded by the frequent development of malnutrition and metabolic derangements in cancer patients, induced by the tumor or by its treatment. These evidence-based guidelines were developed to translate current best evidence and expert opinion into recommendations for multi-disciplinary teams responsible for identification, prevention, and treatment of reversible elements of malnutrition in adult cancer patients. The guidelines were commissioned and financially supported by ESPEN and by the European Partnership for Action Against Cancer (EPAAC), an EU level initiative. Members of the guideline group were selected by ESPEN to include a range of professions and fields of expertise. We searched for meta-analyses, systematic reviews and comparative studies based on clinical questions according to the PICO format. The evidence was evaluated and merged to develop clinical recommendations using the GRADE method. Due to the deficits in the available evidence, relevant still open questions were listed and should be addressed by future studies. Malnutrition and a loss of muscle mass are frequent in cancer patients and have a negative effect on clinical outcome. They may be driven by inadequate food intake, decreased physical activity and catabolic metabolic derangements. To screen for, prevent, assess in detail, monitor and treat malnutrition standard operating procedures, responsibilities and a quality control process should be established at each institution involved in treating cancer patients. All cancer patients should be screened regularly for the risk or the presence of malnutrition. In all patients - with the exception of end of life care - energy and substrate requirements should be met by offering in a step-wise manner nutritional interventions from counseling to parenteral nutrition. However, benefits and risks of nutritional interventions have to be balanced with special consideration in patients with advanced disease. Nutritional care should always be accompanied by exercise training. To counter malnutrition in patients with advanced cancer there are few pharmacological agents and pharmaconutrients with only limited effects. Cancer survivors should engage in regular physical activity and adopt a prudent diet.

[Organization and the Role of Nutirition Support Team]

With the development of specialized nutrition therapy and the need for interdisciplinary approach, nutrition support teams (NSTs) were created to optimize effectiveness and safety of nutritional therapy. NSTs are interdisciplinary support teams with specialty training in nutrition that are typically comprised of physicians, dietitians, nurses, pharmacists, and others. Their role includes nutrition screening, assessment, determination of nutrition needs, recommendations for appropriate nutrition therapy, management of nutrition support therapy, and monitoring. Studies have demonstrated significant improvements in patient nutrition status and improved clinical outcomes as well as reductions in costs when patients were appropriately managed by NSTs. Organization and the role of NSTs are discussed in this review.

Hospital Patients Are Not Eating Their Full Meal: Results of the Canadian 2010–2011 nutritionDay Survey

nutritionDay is a 1-day cross-sectional survey identifying how nutrition care is provided. This paper provides results of the first 2 Canadian nutritionDay surveys. In November 2010 and 2011, data from standardized questionnaires were collected from 193 units in Canadian hospitals consisting of unit demographics and patient information including weight history, health status, nutrition assessment, nutrition therapy, food intake and 30-day outcomes. Results indicated that overall, 46% of the 1905 patients reported weight loss in the previous 3 months, and in half of these it was greater than 5 kg. Only 50% of the units had nutrition teams and nutrition therapy was provided to less than 14% of patients. More than 50% of patients ate less than normal in the previous week and 57% ate less than half of their meal on nutritionDay. Within the next 30 days the majority of patients went home, 10% remained in hospital, and 6% were readmitted. In this study, nutritionDay provided relevant information on nutrition assessment, weight history, food intake, nutrition therapy, length of stay, and outcomes in participating Canadian institutions. Data from 2010 and 2011 can help to both reflect on current practices and define continuous improvements through benchmarking with the overall goal of mitigating suboptimal nutrition intake during hospitalization.

Interdisciplinary Discrepancies Between Parenteral Nutrition Macronutrient Prescribing and Recommendations: Is Body Mass Index a Factor?

BACKGROUND

Formal nutrition training in medical schools and residencies is lacking and needed. Registered dietitians (RDs) are formally trained in nutrition support and considered experts in the nutrition field. Our purpose was to examine prescribing and recommending discrepancies of parenteral nutrition macronutrients between medical residents (MRs) and RDs and compare results with the ASPEN clinical care guidelines. We also looked at discrepancies among obese patients, due to their increased risk of mortality.

MATERIALS AND METHODS

The primary end point of this retrospective review was discrepancies in nonprotein calories (NPCs) and grams of protein (PRO) between MRs and RDs. The secondary end point was discrepancies in NPCs and PRO between MRs and RDs among patients stratified by body mass index category.

RESULTS

MRs prescribed 300 NPCs more versus RDs ( P < .001). When compared with RDs, MRs prescribed fewer NPCs for underweight patients and more for obese patients ( P < .001). The same analysis found that the PRO discrepancies significantly varied by body mass index classification as well ( P = .022). When these results were compared with the ASPEN clinical care guidelines, RDs adhered closer to the guidelines than did MRs in terms of permissive underfeeding of obese patients.

CONCLUSION

It is widely accepted that MRs are in need of increased formal training, and the results of our study confirm this need and suggest a short-term solution of increasing order-writing privileges for the RD. RDs with this privilege may adhere more closely to clinical care guidelines and therefore increase patient safety.

A training program for anthropometric measurements by a dedicated nutrition support team improves nutritional status assessment of the critically ill child

OBJECTIVES

The cornerstone of an optimal nutrition approach in PICUs is to evaluate the nutritional status of any patient. Anthropometric measurements and nutritional indices calculation allow for nutritional status assessment, which is not often part of routine management, as it is considered difficult to perform in this setting. We designed a study to evaluate the impact of a training program by the PICU nutritional support team on the implementation of routine anthropometric measurements on our PICU.

DESIGN

A prospective study was performed over a 2-year period, which included: a baseline evaluation of nutritional assessment, knowledge, anthropometric measurements (weight, height, and head and mid upper arm circumferences), and nutritional indices calculation in patient files. This was followed by a training program to implement the newly developed nutrition assessment guidelines, which included anthropometrical measurements and also the interpretation of these. The impact of this nutritional assessment program was reviewed annually for 2 years after the implementation.

SETTING

PICU--Lyon, France.

PATIENTS AND SUBJECTS

PICU nursing and medical staff, and patients admitted in February 2011, 2012, and 2013.

INTERVENTIONS

Training program.

MEASUREMENTS AND MAIN RESULTS

Ninety-nine percent of staff (n = 145) attended the individual teaching. We found significant progress in nutritional awareness and confidence about nutritional assessment following the teaching program. In addition, an improvement in staff knowledge about undernutrition and its consequences were found. We enrolled 41, 55, and 91 patients in 2011, 2012, and 2013, respectively. There was a significant increase in anthropometric measurements during this time: 32%, 65% (p = 0.002), and 96% in 2013 (p < 0.001). Nutritional indices were calculated in 20%, 74% (p < 0.001), and 96% (p < 0.001) of cases.

CONCLUSIONS

This is the first study, showing that a targeted nutritional assessment teaching program that highlights both the importance and techniques of anthropometrical measurements has successfully been implemented in a PICU. It managed to improve staff knowledge and nutritional practice.